A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?

Command hallucinations.

Impaired memory.

Inappropriate speech patterns.

Rapid mood swings.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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Correct Answer is A

Explanation

The correct answer is Choice A: Consult the client.

Choice A rationale:

Consulting the client is the most appropriate action to respect their privacy and autonomy. It ensures that the client has control over their health information and consents to any disclosures.

Choice B rationale:

Consulting the client's family is not appropriate without the client's explicit permission, as it may violate the client's right to confidentiality.

Choice C rationale:

Contacting the provider may be helpful for clinical guidance, but they cannot disclose the client's health information without the client's consent.

Choice D rationale:

Contacting the facility legal department would be necessary in specific legal situations, but the first step should be to involve the client in the decision-making process to respect their rights.

A. "Snap a rubber band on your wrist when you think about checking the locks.”. B. "Keep a journal of how often you check the locks each night.”. C. "Focus on abdominal breathing whenever you go to check the locks.”. D. "Ask a family member to check the locks for you at night.”. .

Correct Answer is A

Explanation

Choice A rationale:

"Snap a rubber band on your wrist when you think about checking the locks.”. This choice suggests using a painful stimulus (the rubber band snap) as part of the thought-stopping technique. While it may interrupt the client's behavior temporarily, it is not a recommended or ethical approach, as it can cause harm and distress to the client.

Choice B rationale:

"Keep a journal of how often you check the locks each night.”. Keeping a journal may be useful for tracking behavior patterns, but it doesn't address the core issue of obsessive-compulsive disorder. It is essential to provide the client with a more active technique for managing their compulsions, like the one mentioned in choice C.

Choice D rationale:

"Ask a family member to check the locks for you at night.”. This choice does not promote independence or self-management, which is an important goal in treating obsessive-compulsive disorder. It may alleviate the client's anxiety temporarily but does not help the client develop skills to manage their obsessive-compulsive tendencies on their own.

Choice C rationale:

"Focus on abdominal breathing whenever you go to check the locks.”. This response is the most appropriate because it recommends a self-soothing and grounding technique (abdominal breathing) to help the client manage their obsessive thoughts and compulsions. It encourages the client to be more mindful and reduce the urge to perform repetitive behaviors, which is a key aspect of treating obsessive-compulsive disorder. .

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A nurse is assessing a client who has delirium.Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?